overweight in practice opportunities for gp intervention dr brendan o’ shea lecturer in general...
TRANSCRIPT
Overweight in PracticeOpportunities for GP Intervention
Dr Brendan O’ SheaLecturer in General Practice TCD
General Practice Specialty Training & Family Doctor
Leap 2009
Conclusions
Primary care screening + brief counselling did not improveBMI, physical activity, or nutrition in overweight or mildlyobese 5-10 year olds......
and
‘It would be very costly if universally implemented.’
‘These findings are at odds with national policies in countriesincluding the US, UK, and Australia.’
and
LEAP 2009
Only 5-7% of GPs participated.....
• McCallum Z, Wake M, Gerner B, et al. Can Australian general practitioners tackle childhood overweight/obesity? Methods and processes from the LEAP randomized controlled trial. J Paediatr Child Health 2005;41:488–94.
KOALA
• KOALA (Kinder Overweight Activity Lifestyle Actions)• Interventional Study by Mater (Brisbane) on CHOVE• Recruit GPs to case find, and refer to the Study
• Few referrals – 14 (run over18 months) (similar to LEAP)
• eh…..Why ? (Dettori)
‘Oi ! Leave us Koalas outta this ....Obesity - its a Homo Sapiens thing.....’
Dettori & KOALA – Survey of (bold) GPs
‘Only 14 eligible children were identified and referred to the KOALA study by participating GPs – a much lower referral rate than the study required.’
61% reported difficulty broaching the subject39% indicated fear of negative parental response
Dettori, Elliott , Horn; Barriers to management of CHOBE & GP involvement 2009 AFP36(6)
‘Irish GPs’ beliefs & involvement in dietary
counselling in the Primary Care setting in Ireland.’
Survey 247 GPs (58% response rate)
1 in 6 (or 16%) of all consults included dietary guidance
Almost half (44%) indicated they gave dietary advice ‘several times daily’
Most (67%) indicated Practice Nurse routinely gave dietary advice
Most (75%) prescribed anti obesity drugs
Many (52%) indicated having patients who self referred for Bariatric Surgery
2011 Irish Medical Journal, Floyd S, O’ Shea B, Darker C vol 104, no 2.
‘Childhood Obesity in Ireland.Parents fail to recognise, and GPs fail to act.’
Cross sectional GP study, 102 dyads (children 4-14).Questionnaire, consultation, medical record review.
• 16/102 children overweight / obese (CDC criteria); 48 of parents overweight • 81% of parents of overweight children failed to perceived children as
overweight
• Only 1 overweight child had Wt or BMI recorded in the EMR
• 26.7% - 2-3 hours of TV daily and 81 % driven to school
White A, O Brien B, Houlihan T, Darker C & O’ Shea B et al, IMJ 2012 v 5, no 104.
National Survey of GPs on current practice.
20% sample of Irish GPs (n = 527)393 Respondents (80.2% response rate)
Piloted study instrument, based on Dettori.
1(Strongly DISAGREE) 2 3 4(Strongly AGREE) No answer0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
4.07%
16.28%
37.40%
42.24%
0.00%
Childhood overweight is a medical problem (n=393)
1(Strongly DISAGREE) 2 3 4(Strongly AGREE) No answer0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
1.78%
11.45%
41.48%44.78%
0.51%
GPs have a role in childhood overweight management
(n= 393)
1(Strongly DISAGREE) 2 3 4(Strongly AGREE) No answer0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
27.48%
52.42%
12.98%
6.36%
0.76%
Parents view childhood overweight as a medical problem
1(NEVER) 2 3 4(ALWAYS) No answer0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
9.92%
58.02%
27.48%
3.56%1.02%
Are you routinely measuring children's height / weight ?
1(NEVER) 2 3 4(ALWAYS) No answer0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
32.82%
38.17%
20.87%
5.09%3.05%
Do you routinely use guidelines / standards in this area of practice ?
1(NEVER) 2 3 4(ALWAYS) No answer0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
27.74% 27.48% 27.74%
16.28%
0.76%
Do you use age adjusted BMI charts in identifica-tion of overweight children (n=393)
1(NEVER) 2 3 4(ALWAYS) No answer0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
1.53%
36.13%
39.95%
8.14%
14.25%
When an overweight child presents in consultation, how often do you raise the issue of overweight in
the consultation
1(NEVER) 2 3 4(ALWAYS) No answer0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
9.41%
29.52%
51.15%
9.16%
0.76%
Do you find it difficult broaching the subject of childhood overweight with parents ?
1(NEVER) 2 3 4(ALWAYS) No answer0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
7.63%
33.08%
44.27%
14.25%
0.76%
Do you ask overweight children / guardians to return for review of their BMI / weight ?
1(NEVER) 2 3 4(ALWAYS) No answer0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
10.43%
56.74%
22.39%
2.04%
8.40%
How often do overweight children / parents return for review when asked to do so ? (n=
393)
1(Strongly DISAGREE) 2 3 4(Strongly AGREE) No answer0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
10.94%
21.37%
36.64%
28.24%
2.80%
Modest targeted payments would be effective in management of obese children (n = 393)
‘When I see an 11 year old who is 11 stone, I’m tearing my hair out, but telling them they are overweight is difficult. Vulnerable people who are overweight may feel judged if their GP brings it up. I know GPs who have been forthright in their dietary advice, but their Patients have been emotionally traumatised by it.'
Sunday Times Dr Mel Bates Communications Chairman ICGP 2011
“Wealthy obese prefer surgery to better diet…”
Observational study
500 parents and children (5-12 yrs) 10 purposively selected practices (11 GPs) East Leinster areaParents & children serially presenting Invited to participate - parental consent / child assent obtained Children weighed / measured & calculation of BMI
Parents subjected to telephone survey Acceptability 1-2 weeks
Study of Parents / Children on routine weighing and calculation of BMI in practice
Bottom line results from observational study
• 457 (5-12 yr olds) weighed (11 GPs in 10 practices)• 434 dyads completed full survey• Representative sample
How many Parents surveyed felt it was useful to check the weight of their child ?
Bottom line results from observational study
How many Parents surveyed felt it was useful to check the weight of their child ?
98.6% (2013)
Do you believe that having their weight checked by the GP had an impact on the child?
No = 88.9% Yes = 11.1% (Positive Impact 66.7%)
4.4 % of all parents reported negative impact (Upset / Anxious / Angry child)
A few more things......
Of all children recruited (5-12 years)
5-7 year olds least likely to be upset....... Overweight – 1 in 10
Obese – 1 in 411-12 year olds more likely to be upset…..
‘Weighing children.Parents agree, but GPs conflicted.’
O’Shea, Ladewig,Kelly, Reulbach, O’Dowd. Arch Dis Child January 15, 2014 as 10.1136/archdischild-2013-304090
When ? 0……………….12 YearsSample of 1-2 year oldsAttending for last Primary ImmunisationSample of 39 (13 mth olds)
Brief Intervention
Weigh – Objectification of weightSurvey on Eating / Activities
Information Sheet
64% Indicated ‘The Advice encouraged me to improve my child’s health’
Young, Doorley, Darker, O Shea, IMJ 2014.
When ?
• At every consultation – Very / Brief Interventions• Primary Prevention
Prenatal Care Antenatal Care (Activity &
Breastfeeding) 1-2 Yrs and 5-6 Yrs
Education
• ICGP/ROI RCGP Blended Learning Consultation Skills Pack
• 2 Hour CME Module• Blend of evidence / modelled consultations• Suited for individual / group / team learning
Health Service Design
• ROI The Under 6’s / Over 70’s Contract
• Checking weights all of 1-2 and 5-6 year olds
• HSE/ICGP Algorithm, NICE etc
Self checking weight….AdultsN = 150 in Farranfore and Kildare 62% Female, 34% BMI 25-30, 30% BMI >30.
28 % Have no scales26% Indicate they never check weight11% Indicate weighing yearly59% Indicate ‘No Routine’ for checking their own weight
They think in Stones and lbs….We think in terms of BMI and Kilograms….
The Holy Grail
• Stabilisation of prevalence of childhood overweight (Denmark, Switzerland, US cities)
Sooner….or….Later ?
It depends on you and I…
Advanced Practice
• Screening and coding for overweight (100%)• Brief Interventions & Managed Care• Local Resources• Learning Material (Professionals/ Public)• Modest Funding (very) to direct activities• Embedded in vigorously healthy environment• Leadership – Personal / Policy / Political
In the Advanced Practice• High quality EMR, with built in tools• Practice Weight Champions• Congratulate the majority• Support and direct the Overweight Crowd• Learning Materials & Weighing Stations• On site resources (‘Weight Champion’)• Good secondary care referral resources• Uniform / Systematic / Opt Out• Many High Five Moments….
Before Fat and Globesity….
• War• Famine• Bubonic Plague• Syphilis• Tuberculosis• HIV• Swine Flu• Tobacco